Analysis Safety Standards Canadian river raft operators are not required to comply with a uniform set of safety standards. British Columbia alone has legislated operational requirements for river raft operations. In the other provinces and territories, industry associations have worked to encourage outfitters to voluntarily adopt some form of self-regulation. These efforts have had some effect in Ontario and Quebec. In other areas of the country, like Alberta, there is no form of regulation or self-regulation in place--operators essentially apply the safety precautions they deem necessary for their operations. The River Rafting Standards issued by Transport Canada under the Boating Restriction Regulations provide a minimal but reasonable set of safety standards for river rafting operations. Because restrictions under the Boating Restriction Regulations require provinces to seek and/or agree to the application of a restriction, they are not uniformly applied across Canada. They do not apply in Alberta. The lack of uniform safety standards in the river-rafting industry presents a risk to the increasing segment of the population engaged in this type of adventure tourism. The analysis of this occurrence will focus on the risk of injury or death due to not being adequately trained and the risk associated with passengers not being equipped with necessary safety equipment. The analysis will further examine how these risks may have been reduced had the operator been required to meet the minimum requirements of the River Rafting Standards. Training Included in Transport Canada's River Rafting Standards are minimum equipment specifications and training requirements. Each of these topics is covered, in greater depth, in both the B.C. Commercial River Rafting Safety Act and Regulations and the safety regulations developed by the Canadian Rivers Council. In this instance, although both the trip leader and guide had years of river-rafting experience, they were essentially self-taught and had not received any formal river-rafting instruction. Consequently, neither had trip leader or guide certification as defined by the River Rafting Standards, nor were they required to. The business was not a member of any river-rafting association and did not use the guidance of any of the available industry standards. No independent body had assessed the level of difficulty of the rivers on which the company operated. There was no mechanism in place to audit standards. Equipment Lifejackets and Personal Flotation Devices The River Rafting Standards stipulate that either the standard lifejacket, meeting the standard set by the Canadian General Standards Board, or the small vessel lifejacket, (as defined in the Small Vessel Regulations) providing it meets the buoyancy requirements of the standard lifejacket, is to be used. The standard lifejacket is bulky and hampers physical activity but is designed to turn an unconscious person face up and to keep the person's head out of the water. None of the PFDs provided by the trip leader for the use of his passengers were designed to meet the requirements for a standard lifejacket in either performance or flotation. In particular, a PFD is not designed to turn an unconscious person in the water face up. The PFD worn by the victim displayed signs of age and rough service. The PFD manufacturer's information tag sewn on this PFD had, through use, become completely unreadable. The information tag of the PFD had been printed with the caution: This device may lose buoyancy over a period of time and become no longer serviceable. Other PFDs in the inventory of the trip leader were in a similar condition, some with torn fabric or missing buckles. In this occurrence, the PFD was seen to have supported the victim face up when he was thrown from the raft when it capsized. The victim, who was later determined to have suffered a head wound, did not appear to be conscious. When he was recovered, however, he was no longer wearing the PFD. The PFD was recovered and was found to have remained buckled, indicating that it had slipped off the victim, who was most probably unconscious. Helmets Section 32 of the River Rafting Standards states: Protective headgear, of the correct size, and meeting the requirement of CSA Standard CAN3-Z262.1-M83 or equivalent,[7] shall be worn by each person on a raft in waters where risk of head injury may exist. Of the eight helmets the trip leader produced for inspection after the accident, none had the identifying marks of the CSA or an equivalent organization. Although the standards developed by the Canadian Rivers Council stipulate that approved helmets must be worn within 250 m of a rapid, no one on board the FLIP wore protective head gear. On the day of the accident, the number of helmets on the rafts was insufficient for all the participants; helmets were not assigned or distributed between both rafts; the wearing of helmets was not encouraged and neither the trip leader nor the guide wore one. Passengers were exposed to the risk of head injury when the raft capsized and the victim, who suffered a head wound, may have been rendered unconscious because he was not wearing a helmet. Damage to the Raft's Steering Frame The steering frame of the river raft FLIP was damaged when the raft upset while travelling down an embankment toward the launching point on the shore of the river. This damage affected the raft's steering to the extent that the raft's descent of the river was interrupted and the help of the passengers was enlisted to pull the bent steering frame into a position deemed satisfactory to the trip leader. It is not known if the bent steering frame was a factor in the subsequent loss of control of the raft at the ledge. As the raft FLIP approached an abrupt descent in the river, known as the ledge, the attention of the operator was distracted by communication with a passenger. The FLIP capsized after passing over the ledge. The PFDs used by the passengers were not of a design to turn an unconscious person face up in the water, were not fitted to individuals prior to departure from the operational base and, consequently, some did not fit their wearers. The PFD worn by the victim remained fastened but floated free from him after the capsizing. Helmets were not available in sufficient quantities; none of the occupants of the FLIP was wearing a protective helmet. One of the passengers, who may have struck his head on an obstruction as a result of the capsizing, appeared to have lost consciousness. This was a contributory factor in his death by drowning.Findings as to Cause and Contributing Factors As the raft FLIP approached an abrupt descent in the river, known as the ledge, the attention of the operator was distracted by communication with a passenger. The FLIP capsized after passing over the ledge. The PFDs used by the passengers were not of a design to turn an unconscious person face up in the water, were not fitted to individuals prior to departure from the operational base and, consequently, some did not fit their wearers. The PFD worn by the victim remained fastened but floated free from him after the capsizing. Helmets were not available in sufficient quantities; none of the occupants of the FLIP was wearing a protective helmet. One of the passengers, who may have struck his head on an obstruction as a result of the capsizing, appeared to have lost consciousness. This was a contributory factor in his death by drowning. There was no effective means of communication between the rafts or from a raft to a base unit because neither raft carried any communication equipment. Although the water temperature was below 10 degrees Celsius, neither the trip leader nor the guide was wearing a wet suit and, as such, both were susceptible to hypothermia when immersed. No sailing plan or passenger count was filed with search and rescue, or other resources, prior to departure. Small passenger vessels of not more than 5 tons, and carrying not more than 12 passengers, are exempt from annual inspections. At present, in Canada, mandatory training and operator licensing are not required for passenger vessels of 5 tons or less. The River Rafting Standards, intended to provide a minimumstandard of protection for the fare-paying public, are not applicable across the country.Findings as to Risk There was no effective means of communication between the rafts or from a raft to a base unit because neither raft carried any communication equipment. Although the water temperature was below 10 degrees Celsius, neither the trip leader nor the guide was wearing a wet suit and, as such, both were susceptible to hypothermia when immersed. No sailing plan or passenger count was filed with search and rescue, or other resources, prior to departure. Small passenger vessels of not more than 5 tons, and carrying not more than 12 passengers, are exempt from annual inspections. At present, in Canada, mandatory training and operator licensing are not required for passenger vessels of 5 tons or less. The River Rafting Standards, intended to provide a minimumstandard of protection for the fare-paying public, are not applicable across the country. The following, rescue raft, the FLOP, was a distance away from the FLIP, and her occupants did not observe the accident. The PFDs worn by the occupants were below the standard stipulated by the River Rafting Standards, and some had torn fabric or missing buckles.Other Findings The following, rescue raft, the FLOP, was a distance away from the FLIP, and her occupants did not observe the accident. The PFDs worn by the occupants were below the standard stipulated by the River Rafting Standards, and some had torn fabric or missing buckles. As a result of this accident, the TSB apprised, via TSB Marine Safety Information letter MSI 06/00, the Government of the Province of Alberta of the safety shortcomings in commercial river-rafting operations with respect to, inter alia, the use and carriage of safety equipment, the knowledge and training of operators, and the inadequacy in safety standards applicable to such commercial operations. In addition, the owner/operator of this commercial river-rafting company was issued a deficiency notice under the Canada Shipping Act by Transport Canada, Marine Safety (TCMS). His commercial river-rafting operation was suspended until it met with the requirements of the River Rafting Standards to the satisfaction of TCMS. In the spring of 2000 the company was re-inspected by TCMS. At that time the operation was found to be in compliance with the River Rafting Standards.Safety Action As a result of this accident, the TSB apprised, via TSB Marine Safety Information letter MSI 06/00, the Government of the Province of Alberta of the safety shortcomings in commercial river-rafting operations with respect to, inter alia, the use and carriage of safety equipment, the knowledge and training of operators, and the inadequacy in safety standards applicable to such commercial operations. In addition, the owner/operator of this commercial river-rafting company was issued a deficiency notice under the Canada Shipping Act by Transport Canada, Marine Safety (TCMS). His commercial river-rafting operation was suspended until it met with the requirements of the River Rafting Standards to the satisfaction of TCMS. In the spring of 2000 the company was re-inspected by TCMS. At that time the operation was found to be in compliance with the River Rafting Standards.